Basic Information
| Provider Information | |||||||||
| NPI: | 1679662712 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FESTA | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9955 POPLAR TENT RD | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280279314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043161161 | ||||||||
| FaxNumber: | 7043161162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 04/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD047711L | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MA60114 | NJ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2022-00748 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6672396 | 01 | CIGNA | OTHER | 0713315000 | 01 | AMERIHEALTH HMO, KESYSTONE, IBC | OTHER | 010002623 | 01 | AMERICHOICE | OTHER | 6462804 | 05 | NJ | MEDICAID |